CFIR Implementation Framework and Application to the VISN

CFIR Implementation Framework and Application to the VISN 11 Stroke Collaborative Laura J. Damschroder, MS, MPH Diabetes QUERI Co-IRC Ann Arbor Center for Practice Management & Outcomes Research & Teresa Damush, Ph. D Stroke QUERI IRC VA HSRD Center of Excellence on Implementing Evidence-Based Practice, Roudebush VAMC

Consolidated Framework for Implementation Research (CFIR) n A comprehensive framework to promote consistent use of constructs, terminology, and definitions § § § Consolidate existing models and frameworks Comprehensive in scope Tailor use to the setting 2

Consolidated Framework for Implementation Research (CFIR) Intervention at Time 0 Intervention at Time 1 Hard Core External Context 3 Soft Periphery Hard Core Soft Periphery Internal Context

Consolidated Framework for Implementation Research (CFIR) Intervention at Time 0 Intervention at Time 1 External Context 4 Hard Core Soft Periphery Process Hard Core Soft Periphery Internal Context

Dependent Variable of Interest n Implementation § The process of putting an intervention into use in an organization Ø n Fidelity § n The vehicle by which a new practice is assimilated into an organization Degree to which an intervention or program is delivered as intended Implementation Effectiveness § Three general categories: Widespread avoidance (non-use) Ø Meager and unenthusiastic use (compliant use) Ø Skilled, enthusiastic, consistent use (committed use) Ø 5

Application of the CFIR Consists of 31 individual constructs n Cannot use them all in every study n § § And not all will apply A priori assessment of which constructs to include Ø Modifiable n & non-modifiable constructs Determine levels at which each construct may apply § E. g. , teams, departments, clinics, regions 6

VISN 11 Stroke Collaborative VISN 11 Administration/CMO initiated an Acute Stroke Care QI project n Asked VA Stroke QUERI Center for assistance n Each of 7 VA sites identified clinical champion and QI team n Partnered with COE Health Care System Redesign expert, Heather Woodward-Hagg n 7

VISN 11 Stroke Collaborative 3 Day Summit – Trained QI teams in LEAN methodology to conduct Rapid Improvement Projects n Teams collectively voted to: n § § Implement electronic stroke order sets in ED and Admissions Target 2 JC acute stroke care processes Ø Lipid Management Ø Dysphagia Screening 8

FAB Model-Facilitating the Adoption of Best Practices Based upon Diffusion of Innovations, Translation Model, and Social Learning Theory 9

Methods: QI project Ø Use of Sharepoint Site – Training Resources- LEAN – Tools for Sites Examples of Administration letters CAC protocols for Stroke Order Sets Social Marketing – Stall Street Journal Ø External Facilitation: Bi-weekly Coaching – All 7 sites monthly call – One on one coaching as needed Ø Networking: Within and Between Sites Ø Monthly QI data reported on 2 JC processes 10

Methods: Evaluation n Quantitative § § n % improvement on 2 JC stroke care processes Dose of biweekly coaching Qualitative § § § Evaluate the FAB Domains Barriers and Facilitators of Implementation Analyze contents of biweekly coaching calls 11

Application of CFIR Paucity of implementation measures n Used the CFIR as a resource for constructing semi structured interviews of FAB domains with 7 QI teams n Incorporated measures/questions from previous work and mixed with items from CFIR and reviewed with Laura. n 12

CFIR Application n Communication and Diffusion Networks § § § Key components of the colloborative intervention – Training summit, coaching calls, shared resources on listserv Viewed the teams as change agents who would return to facility and diffuse the innovation to peers. In CFIR, described as “Social Capital” Ø Internal bonding -relationships within site Ø External bridging – relationships across sites 13

CFIR Application (continued) n We asked questions § § § Communications within teams Communications to other units Communication with administration Communication with other 6 sites Asked about frequency Record of coaching call attendance 14

CFIR Application: Implementation Process n Innovation may not be used daily because of stroke volume – thus, difficult to observe § Implementation processes Ø process maps Ø PDSA plans § Listed possible processes, date of implementation, and degree of implementation 1 -10 (CFIR) Ø Locally tailored stroke order set (CAC –VISN/QUERI) Ø Gained dept and admin approvals Ø Trained staff and implemented order sets Ø Addressed barriers – night staff not trained

Conclusions: CFIR… Embraces, consolidates, and standardizes key constructs from other models n Agnostic to specific models and theories n Provides a pragmatic structure for evaluating complex implementations n Helps to organize findings across disparate implementations n Paves the way for cross-study research n 16

Next Steps n Continue to evaluate usefulness of the CFIR § § § n Build database of evidence § n n Is terminology/language coherent? Does it promote comparison of results across settings and studies over time? Does it stimulate new theoretical developments? Shared Wikipedia of definitions and evidence Factor analysis of findings to consolidate constructs and facilitate subsequent analyses (fewer variables, greater power) Promote use by QUERIs 17

Contact Info n Laura Damschroder § § n Laura. Damschroder@va. gov 734 -845 -3603 Teresa Damush § § § tdamush@iupui. edu Teresa. Damush@va. gov 317 -988 -2258 18